Protein machines and lipid assemblies: current views of cell membrane fusion

Protein machines and lipid bilayers both play central roles in cell membrane fusion, a process crucial to life. Recent results provide clues to how both components function in fusion. Recent observations suggest a common mechanism by which very different fusion machines (from lipid-enveloped viruses and synaptic vesicles) may function to produce compartment-joining pores. This mechanism presumes that fusion proteins act as machines that use stored conformational energy to assemble closely juxtaposed lipid bilayers, bend these to form fusion-competent structures, stabilize unfavorable lipid structures and destabilize a committed intermediate to drive fusion pore formation.

An in vivo comparison of the kinetics of protein and lipid deposition on group II and group IV frequent-replacement contact lenses

PURPOSE

To investigate the degree and rate of deposition of protein and lipid on FDA group II and group IV contact lens materials over a period of up to 28 days of wear.

METHODS

Twenty-two subjects wore a group IV lens (Acuvue) and a group II lens (Soflens 66) in a randomized, cross-over study. The lenses were randomly worn for periods between 1 and 28 days and then collected for laboratory-based deposition analysis.

RESULTS

The group II lenses revealed an increased degree of lipoidal spoilage (p < 0.0001) and the group IV lenses exhibited increased protein spoilage (p < 0.0001). Surface protein for both materials reached a maximum after 1 day and did not increase over the 4-week wearing period (p = NS). Total protein for group IV lenses reached a maximum between 1 and 7 days and then reached a plateau, with no further increase occurring (p = NS), whereas total protein accumulation on the group II lens continued to increase across all time periods (p < 0.05). Lipid deposition on the group IV lens was maximal after 1 day and increased no further (p = NS), whereas lipid deposition on the group II material monotonously increased and progressively built-up over the 4 weeks of wear (p < 0.0001).

CONCLUSIONS

The kinetics of contact lens deposition is mediated by the chemical structure of the contact lens material under consideration. Protein deposition occurs rapidly with group IV materials before reaching a maximum, whereas N-vinyl pyrrolidone-containing group II materials progressively accumulate protein and lipid deposits, with no plateau occurring.

Ethanol with a mixed meal increases postprandial triacylglycerol but decreases postprandial non-esterified fatty acid concentrations

Plasma triacylglycerol concentrations increase after the acute ingestion of alcohol (specifically ethanol). However, the effect of ethanol when consumed with a mixed meal has not been well studied. The objective of the present study was to determine the perturbations of lipid metabolism that occur after ingestion of ethanol in combination with a mixed meal of specific fatty acid composition. Blood samples were taken from seven healthy male subjects before and after a mixed meal, with and without ethanol. The specific fatty acid composition of the test meal allowed the fatty acids to be traced into the plasma non-esterified fatty acid pool during the postprandial period. Statistical analysis by repeated measures ANOVA showed significant effects of ethanol. For example, postprandial lipaemia was enhanced after the ethanol test meal compared with the control (P < 0.05), mainly due to increases in triacylglycerol-rich lipoproteins in the flotation range Sf 60-400 (VLDL1) (P < 0.05); those in the range Sf 20-60 (VLDL2) and also Sf > 400 (chylomicrons) were not significantly affected. The later postprandial increase in plasma non-esterified fatty acid concentrations was reduced after the ingestion of ethanol (P < 0.001), but the proportions of palmitoleic acid (a marker of fatty acid content of the test meal) and of linoleic acid (a marker of endogenous lipolysis) were not affected. The results suggest a primary effect of ethanol on the stimulation of secretion of large VLDL particles, which then compete for clearance with chylomicrons by lipoprotein lipase. The results do not support an effect of ethanol on the release of non-esterified fatty acid into the plasma. The suppression of plasma non-esterified fatty acid concentrations during the postprandial period may contribute towards the beneficial effects of moderate ethanol consumption.

Selective expansion of intraepithelial lymphocytes expressing the HLA-E-specific natural killer receptor CD94 in celiac disease

BACKGROUND & AIMS

Celiac disease is a gluten-induced enteropathy characterized by the presence of gliadin-specific CD4(+) T cells in the lamina propria and by a prominent intraepithelial T-cell infiltration of unknown mechanism. The aim of this study was to characterize the subset(s) of intraepithelial lymphocytes (IELs) expanding during active celiac disease to provide insights into the mechanisms involved in their expansion.

METHODS

Flow-cytometric analysis of isolated IELs and/or immunohistochemical staining of frozen sections were performed in 51 celiac patients and 50 controls with a panel of monoclonal antibodies against T-cell and natural killer (NK) receptors. In addition, in vitro studies were performed to identify candidate stimuli for NK receptor expression.

RESULTS

In normal intestine, different proportions of IELs, which were mainly T cells, expressed the NK receptors CD94/NKG2, NKR-P1A, KIR2D/3D, NKp46, Pen5, or CD56. During the active phase of celiac disease, the frequency of CD94(+) IELs, which were mostly alphabeta T cells, was conspicuously increased over controls. In contrast, the expression of other NK markers was not modified. Furthermore, expression of CD94 could be selectively induced in vitro by T-cell receptor activation and/or interleukin 15, a cytokine produced by intestinal epithelial cells.

CONCLUSIONS

The gut epithelium favors the development of T cells that express NK receptors. In active celiac disease, there is a specific and selective increase of IELs expressing CD94, the HLA-E-specific NK receptor that may be related to T-cell receptor activation and/or interleukin 15 secretion.

Who cares? A focus group study on follow up care after discharge from hospital

AIM

To ascertain general practitioners', patients' and hospital staff's perspectives on post discharge problems and other problems related to hospital liaison in the Darwin urban area. To identify stakeholders who have a role in addressing these problems and develop locally appropriate responses to improve post hospital discharge patient care.

METHOD

A qualitative study using three focus groups was conducted with seven GPs, six ex-patients of the study hospital and 11 hospital staff. The problems and proposed strategies identified by these groups were then fed back to stakeholders for comment in order to generate recommendations to improve post discharge care.

RESULTS

The main themes generated were: lack of recognition of the potential role of the GP and patient by the hospital; poor communication between the hospital, GPs and patients; and, lack of resources to improve information flow. Specifically, 'not being listened to' by hospital doctors, nurses and GPs was a major theme of the patient focus group and was equated with a 'not caring' attitude by some hospital staff and GPs. Twelve strategies were generated by the focus groups with considerable overlap of issues. The main strategies were aimed at GP liaison by providing GPs and patients with timely, adequate and comprehensible information as part of their 'duty of care'. General practitioners, however, need to provide legible, relevant and concise referral letters to facilitate this process.

CONCLUSIONS

This study highlights the need for improved communication between the GP and the hospital to redress the lack of recognition of GPs. The appointment of a GP/hospital liaison officer in the study hospital could address this issue as well as others of patient empowerment and advocacy, and partnerships in health care. This project has also highlighted the importance of consulting patients and the value of their perspective to complement GP and hospital viewpoints.

Pamidronate therapy as prevention of bone loss following renal transplantation

BACKGROUND

Very rapid bone loss, osteopenia and skeletal morbidity after renal transplantation have been well documented and found to occur in a sex dependent fashion. Glucocorticoids, cyclosporine and pre-existing uremic osteodystrophy have been implicated in the pathogenesis of the skeletal lesions. Glucocorticoid induced osteopenia is also a serious clinical problem in patients with various nonrenal diseases and can be prevented, or at least attenuated, by pamidronate and other bisphosphonates.

METHOD

We prospectively studied 26 male patients undergoing renal transplantation, and randomized them to receive either placebo or intravenous pamidronate (0.5 mg/kg) at the time of transplantation and again one month later. All patients received immunosuppression comprising prednisolone, cyclosporine and azathioprine. The bone mineral density (BMD) of the second, third and fourth lumbar vertebrae and of the femoral neck was measured at the time of transplantation and at three months and 12 months after transplantation using dual energy X-ray absorptiometry (DXA).

RESULTS

Twelve months after transplantation, the mean (+/- SEM) BMD of the lumbar vertebrae in patients who received placebo had decreased 6.4% (P < 0.05). In contrast, patients who received pamidronate experienced no significant reduction of BMD at the lumbar vertebrae. At the femoral neck, placebo-treated patients showed a reduction of BMD of 9% (P < 0.005), whereas there was no significant change in the pamidronate treated group. The two study groups had similar patient profiles, serum parathyroid hormone (PTH) and aluminium concentrations. After transplantation, comparable falls in the serum creatinine and PTH concentration were found in the two groups. Apart from transient hypocalcemia in two patients, no significant adverse effects of pamidronate were noted.

CONCLUSION

This study has shown that the early rapid bone loss that occurs in men during the first 12 months after renal transplantation can be prevented by two intravenous doses of pamidronate given at transplantation and one month later. The regimen was simple to administer, well tolerated and potentially applicable to other clinical groups of glucocorticoid treatment patients.

North Carolina macular dystrophy (MCDR1) locus: a fine resolution genetic map and haplotype analysis

PURPOSE

We previously reported linkage of North Carolina macular dystrophy in a single isolated family to a broad region on chromosome 6q16. In order to refine the localization of the MCDR1 gene (North Carolina macular dystrophy), additional families with this disease and new markers were studied.

METHODS

We ascertained 10 families with the North Carolina macular dystrophy phenotype (MCDR1). These families were of various ethnic and geographic origins such as Caucasian, Mayan Indian, African-American, French, British, German, and American of European decent. Two hundred thirty-two individuals in these families underwent comprehensive ophthalmic examinations and blood was collected for genotyping. One hundred seventeen were found to be affected. Linkage simulation studies were performed. Two-point linkage, haplotype analysis, and multipoint linkage was performed using VITESSE and FASTLINK. HOMOG was used to test for genetic heterogeneity.

RESULTS

The clinical features were consistent with the diagnosis of North Carolina macular dystrophy in all families. Multipoint linkage analysis indicates that the MCDR1 gene is in the interval between D6D249 and D6S1671 with a maximum LOD score of 41.52. There was no evidence of genetic heterogeneity among the families studied. Families 765, 768, 772, 1193, and 1292 shared the same chromosomal haplotype in this region.

CONCLUSIONS

This is the largest single data set of families with the MCDR1 phenotype. The single large family from North Carolina continues to be informative for the closest flanking markers and alone supports the minimal candidate region as suggested by previous studies. There remains no evidence of genetic heterogeneity in this disease. Most of the American families appear to have descended from the same ancestral mutation. The remaining families could each represent independent origins of the mutation in the MCDR1 gene.

Meloidogyne incognita Surface Antigen Epitopes in Infected Arabidopsis Roots

Surface-coat epitopes of Meloidogyne incognita were detected in root tissues of Arabidopsis thaliana during migration and feeding site formation. A whole-mount root technique was used for immunolocalization of surface coat epitopes in A. thaliana, with the aid of a monoclonal antibody raised specifically against the outer surface of infective juveniles of M. incognita. The antibody, which was Meloidogyne-specific, recognized a fucosyl-bearing glycoprotein in the surface coat. During migration in host tissues the surface coat was shed, initially accumulating in the intercellular spaces next to the juvenile and later at cell junctions farther from the nematode. Upon induction of giant cell formation, the antibody bound to proximally located companion cells and sieve elements of the phloem.

Emergency services for children and young people

The health care needs of a child are very different to those of an adult but when it comes to paediatric care in the accident and emergency department there is little or no consideration of children's specific needs. This article describes the present situation and makes recommendations for the future.

A program of acquired immune deficiency syndrome education for nurses in Romania

After the fall of the communist government in Romania, many children were found to be human immunodeficiency virus (HIV) infected. The majority of these children were abandoned and currently live in orphanages. The children have been cared for on a day-to-day basis by nurses with little general nursing education and even less HIV education. The Romanian-American Pediatric AIDS Education and Clinical Research Program was established at Texas Children's Hospital and Baylor College of Medicine in May, 1996 to aid in the education of Romanian nurses. Syllabi developed by the U.S. nursing team were initially piloted in three pediatric HIV centers in Romania in July, 1997. Since that time, two annual nursing symposia have been held offering topics on general pediatrics and HIV-related content. The purpose of this article is to describe a program of HIV education for nurses in Romania.

The MexA-MexB-OprM multidrug efflux system of Pseudomonas aeruginosa is growth-phase regulated

Intrinsic antibiotic resistance in Pseudomonas aeruginosa is attributed to low outer membrane permeability and drug efflux mediated by the products of mexAmexBoprM efflux operon. Using a mexA-phoA fusion, expression of the efflux genes was assessed as a function of growth in a variety of strains. The efflux operon was growth-phase regulated in both wild-type and nalB strains, being minimally expressed in lag phase and increasing in log to late log phase. MexR, the only known regulator of MexAMexBOprM and target of mutation in nalB strains, was not involved in the growth-phase regulation. The las cascade regulates genes based on increased cell-density, but a deletion in lasR had no effect on mexAmexBoprM expression. Putative recognition sequences for AlgT/U and RpoN were identified upstream of mexA, but algT/U and rpoN null mutants also had no effect on mexAmexBoprM expression.

Effects of an oral and intravenous fat load on adipose tissue and forearm lipid metabolism

We have studied the fate of lipoprotein lipase (LPL)-derived fatty acids by measuring arteriovenous differences across subcutaneous adipose tissue and skeletal muscle in vivo. Six subjects were fasted overnight and were then given 40 g of triacylglycerol either orally or as an intravenous infusion over 4 h. Intracellular lipolysis (hormone-sensitive lipase action; HSL) was suppressed after both oral and intravenous fat loads (P < 0.001). Insulin, a major regulator of HSL activity, showed little change after either oral or intravenous fat load, suggesting that suppression of HSL action occurred independently of insulin. The rate of action of LPL (measured as triacylglycerol extraction) increased with both oral and intravenous fat loads in adipose tissue (P = 0.002) and skeletal muscle (P = 0.001). There was increased escape of LPL-derived fatty acids into the circulation from adipose tissue, shown by lack of reesterification of fatty acids. There was no release into the circulation of LPL-derived fatty acids from skeletal muscle. These results suggest that insulin is not essential for HSL suppression or increased triacylglycerol clearance but is important in reesterification of fatty acids in adipose tissue but not uptake by skeletal muscle, thus affecting fatty acid partitioning between adipose tissue and the circulation, postprandial nonesterified fatty acid concentrations, and hepatic very low density lipoprotein secretion.

An outbreak of hepatitis A associated with an infected foodhandler

OBJECTIVE

The recommended criteria for public notification of a hepatitis A virus (HAV)-infected foodhandler include assessment of the foodhandler's hygiene and symptoms. In October 1994, a Kentucky health department received a report of a catering company foodhandler with hepatitis A. Patrons were not offered immune globulin because the foodhandler's hygiene was assessed to be good and he denied having diarrhea. During early November, 29 cases of hepatitis A were reported among people who had attended an event catered by this company. Two local health departments and the Centers for Disease Control and Prevention, in collaboration with two state health departments, undertook an investigation to determine the extent of the outbreak, to identify the foods and event characteristics associated with illness, and to investigate the apparent failure of the criteria for determining when immune globulin (IG) should be offered to exposed members of the public.

METHODS

Cases were IgM anti-HAV-positive people with onset of symptoms during October or November who had eaten foods prepared by the catering company. To determine the outbreak's extent and factors associated with illness, the authors interviewed all case patients and the infected foodhandler and collected information on menus and other event characteristics. To investigate characteristics of events associated with transmission, the authors conducted a retrospective analysis comparing the risk of illness by selected event characteristics. To evaluate what foods were associated with illness, they conducted a retrospective cohort study of attendees of four events with high attack rates.

RESULTS

A total of 91 cases were identified. At least one case was reported from 21 (51%) of the 41 catered events. The overall attack rate was 7% among the 1318 people who attended these events (range 0 to 75% per event). Attending an event at which there was no on-site sink (relative risk [RR] = 2.3, 95% confidence interval [CI] 1.4, 3.8) or no on-site kitchen (RR = 1.9, 95% Cl 1.1, 2.9) was associated with illness. For three events with high attack rates, eating at least one of several uncooked foods was associated with illness, with RRs ranging from 8 to undefined.

CONCLUSION

A large hepatitis A outbreak resulted from an infected foodhandler with apparent good hygiene and no reported diarrhea who prepared many uncooked foods served at catered events. Assessing hygiene and symptoms s subjective, and may be difficult to accomplish. The effectiveness of the recommended criteria for determining when IG should be provided to exposed members of the public needs to be evaluated.

Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm

BACKGROUND

The treatment of deliberate self-harm (parasuicide) remains limited in efficacy. Despite a range of psychosocial, educational and pharmacological interventions only one approach, dialectical behaviour therapy, a form of cognitive-behaviour therapy (CBT), has been shown to reduce repeat episodes, but this is lengthy and intensive and difficult to extrapolate to busy clinical practice. We investigated the effectiveness of a new manual-based treatment varying from bibliotherapy (six self-help booklets) alone to six sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behaviour therapy.

METHODS

Thirty-four patients, aged between 16 and 50, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with manual-assisted cognitive-behaviour therapy (MACT N = 18) or treatment as usual (TAU N = 16). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined.

RESULTS

Thirty-two patients (18 MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0.17/month MACT; 0.37/month TAU; P = 0.11) and self-rated depressive symptoms also improved (P = 0.03). The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with MACT (P = 0.22).

CONCLUSIONS

Although limited by the small sample, the results of this pilot study suggest that this new form of cognitive-behaviour therapy is promising in its efficacy and feasible in clinical practice.

Recovery of positive future thinking within a high-risk parasuicide group: results from a pilot randomized controlled trial

OBJECTIVES

The research examined: (i) whether high risk parasuicide patients showed a deficit in positive future thinking but no increase in negative future thinking; and (ii) whether such a deficit could be remedied by a brief, manual-assisted psychological intervention (manual assisted cognitive-behaviour therapy; MACT).

DESIGN

A cross-sectional, mixed model design was used to assess differences between a sample of high risk parasuicide patients and matched controls on future thinking. A longitudinal mixed model design was used to assess changes in future thinking in the different groups over time.

METHODS

Parasuicide patients with a history of previous suicidal behaviour and personality disturbance were compared with a matched group of community controls on an adapted fluency measure of future thinking, which measured both quantitative and qualitative aspects of anticipated experiences. Patients were then randomly allocated to either the specific intervention (MACT) or treatment as usual (TAU) and assessed again at 6 month follow-up.

RESULTS

Parasuicide patients showed reduced positive future thinking but no increased negative future thinking. Patients who received MACT showed a significant improvement in positive future thinking over the follow-up period whereas the TAU group showed no such improvement. However, interpretation of this finding was made more difficult by the control group also showing a significant improvement in positive future thinking.

CONCLUSION

The results confirm that parasuicide patients exhibit a relative deficit in positive future thinking and suggest that this lack of positive future thinking may be remedied, at least partly, by a brief intervention.

Phenotype of a British North Carolina macular dystrophy family linked to chromosome 6q

AIMS

To document the phenotype of an autosomal dominant macular dystrophy diagnosed as having North Carolina macular dystrophy (NCMD) in this British family, and to verify that the disease locus corresponds with that of MCDR1 on chromosome 6q.

METHODS

37 family members were examined and the phenotype characterised. DNA samples from the affected members, 19 unaffected and five spouses, were used to perform linkage analysis with six microsatellite marker loci situated within the MCDR1 region of chromosome 6q.

RESULTS

Every affected family member had lesions characteristic of NCMD, which developed early in life and usually remain stable thereafter. Although fundus changes are evident in the periphery, all tests revealed that functional loss is restricted to the macula. Some patients with large macular lesions had good visual acuity with fixation at the edge of the lesion at 5 degrees eccentricity. Significant linkage to the MCDR1 locus on chromosome 6q was obtained with three marker loci, with a maximum lod score of 5.9 (q = 0.00) obtained with D6S249.

CONCLUSION

This family has the typical phenotype NCMD, and the causative gene was linked to the disease locus (MCDR1) on chromosome 6q. Early onset and localisation of the disease to the central macula allow specialisation of eccentric retina in some eyes with resultant good visual acuity.

Influence of the MexAB-OprM multidrug efflux system on quorum sensing in Pseudomonas aeruginosa

Pseudomonas aeruginosa nalB mutants which hyperexpress the MexAB-OprM multidrug efflux system produce reduced levels of several extracellular virulence factors known to be regulated by quorum sensing. Such mutants also produce less acylated homoserine lactone autoinducer PAI-1, consistent with an observed reduction in lasI expression. These data suggest that PAI-1 is a substrate for MexAB-OprM, and its resulting exclusion from cells hyperexpressing MexAB-OprM limits PAI-1-dependent activation of lasI and the virulence genes.

Quorum-sensing and siderophore biosynthesis in Pseudomonas aeruginosa: lasR/lasI mutants exhibit reduced pyoverdine biosynthesis

Cell density-dependent gene expression in Pseudomonas aeruginosa is controlled, in part, by the quorum-sensing regulator LasR. lasR null mutants exhibited a reproducible 2-fold decrease in production of the catecholate-hydroxamate siderophore pyoverdine during grown under iron-limiting conditions. Similarly, lasI mutants defective in the biosynthesis of the autoinducer PAI-1 also exhibited a 2-fold decrease in pyoverdine production which could be largely restored upon addition of exogenous PAI-1. lasR mutants were not altered with respect to expression of the pvdD gene involved in the synthesis of the peptide portion of pyoverdine, indicating that some other pyoverdine biosynthetic gene(s) were affected by the LasRI status of the cell. This represents the first report of quorum-sensing regulation of siderophore production in bacteria and highlights the fact that cell density, while not an essential signal for pyoverdine expression, does enhance production of this siderophore.

Rapid chylomicron appearance following sequential meals: effects of second meal composition

Previous studies have noted the presence of an early postprandial peak in plasma triacylglycerol concentrations following successive fat-rich meals. An earlier study has shown that the triacylglycerol in this early peak originates from a previous meal. The present study was performed to investigate the effects of different second meals on the plasma triacylglycerol response. Six healthy subjects were studied on four occasions each. At 5 h following a fat-rich breakfast they ingested one of the following in a balanced design: a fat-rich meal, a low-fat meal, water or nothing by mouth. Blood samples were taken for 2.5 h following the second meal. An early peak in chylomicron and plasma triacylglycerol concentrations was seen following both low-fat and fat-rich second meals but not following water. During studies investigating postprandial lipaemia, further meals must be avoided, even if they contain no fat, although water may be allowed.

Estimation and relevance of depth correction in paediatric renal studies

Measurement of absolute renal function by gamma camera techniques requires knowledge of kidney depth to correct for soft tissue attenuation, there is debate about the need to take depth into account when only relative renal function is estimated. The aim of this study was to derive a formula for renal depth in children and to assess the importance of depth correction when relative renal function is assessed with dimercaptosuccinic acid (DMSA) on the gamma camera. In this study, kidney depths were derived from measurements on abdominal computerised tomography (CT) images in 57 children in the supine position with two normally located kidneys. Using best-subset regression analysis, one formula for both left and right kidney depth (KD, cm) was developed based on the easily measured parameters of height (H, cm) and body weight (W, kg). The inclusion of extra variables was found to significantly improve the model compared with a model using weight alone (P<0.005). A second group of 19 children who underwent technetium-99m DMSA scans, had differential function estimated from both anterior and posterior views and the geometric mean method. The mean difference in differential renal function calculated by the geometric mean method versus the posterior image was only 1.2%. In conclusion, we present a new formula for the estimation of paediatric kidney depth for the absolute quantitation of kidney uptake. Further, for normally located kidneys it appears unnecessary to use the geometric mean method or to correct for individual renal depth when calculating differential function.

Randomised controlled trial of two models of care for discharged psychiatric patients

OBJECTIVE

To compare the clinical outcome and costs of care of psychiatric patients allocated to community multidisciplinary teams or to hospital based care programmes after discharge from inpatient care.

DESIGN

Randomised controlled trial.

SETTING

Inner London (Paddington and North Kensington) and outer London (Brent) psychiatric services.

SUBJECTS

155 patients with severe mental illness with a previous admission within the past 2 years.

MAIN OUTCOME MEASURES

Ratings of clinical psychopathology, depression, anxiety, and social functioning; comprehensive costs of health care.

RESULTS

Clinical outcomes were available for 133 patients and cost data for 144 patients after 1 year. The clinical outcomes of the two models of care were essentially similar, but admission to hospital was more likely in the hospital based care group and the costs of health care were 14% greater per patient than in the community group. This difference, however, was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London. This was explained largely by greater inpatient care for outer London patients (58 median bed days v 18 for inner London patients), more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study.

CONCLUSION

Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital. When psychiatric bed requirements are insufficient for a population, however, neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes, with disintegration and discontinuity of psychiatric services leading to escalating costs.

Dosimetry of pediatric radiopharmaceuticals: uniformity of effective dose and a simple aid for its estimation

Formulae were investigated for predicting the effective dose to children, per unit administered activity of various pediatric radiopharmaceuticals, based only on the weight of the patient. Their influence on the uniformity of effective dose from total administered activity was also examined.

METHODS

The formulae were obtained from calculations of effective dose per unit administered activity (mSv x MBq[-1]) for five anthropomorphic mathematical phantoms applicable for newborn, 1-yr-, 5-yr-, 10-yr- and 15-yr-old children, having body weights of 3.4, 9.8, 19, 32 and 57 kg, respectively, using published biokinetic models.

RESULTS

In general, there was good linear correlation between effective dose per unit administered activity and inverse weight but, for some radiopharmaceuticals, logarithmic regression on weight provided a better fit to the data. An administered activity schedule based on body surface area, used with these formulae, resulted in reasonable uniformity of effective dose for children of all ages, with varying degrees of uniformity for different radiopharmaceuticals (coefficient of variation (COV) up to 20%). Individual activity schedules for separate radiopharmaceuticals gave best uniformity (COV < 7%) while a single general schedule, based on the mean results of the present study, yielded acceptable uniformity (COV < or = 10%) over the pediatric range.

CONCLUSION

Effective dose per unit administered activity (mSv x MBq[-1]) of pediatric radiopharmaceuticals can be predicted from body weight alone by using simple formulae, and appropriately choosing the administered activity schedule leads to similar values of effective dose for children of all ages from a given radiopharmaceutical procedure.

Development of a radiopharmaceutical activity schedule for technetium-99m dimercaptosuccinic acid in children based on image quality criteria

The aim of this study was to determine an activity schedule (amount of administered activity in relation to body weight) for technetium-99m dimercaptosuccinic acid examinations in children, from information present in renal scintigraphic images. Scans from 48 children (5 weeks to 14.8 years old) were graded for image quality according to the clarity of both kidney outline and internal structure. Numerical image data (kidney and background counts, signal-to-noise ratio) were associated with these subjective gradings to formulate three criteria, specifying the required values of the above-measured parameters to yield optimum grades of image quality. When applied to derived functions, a kidney uptake of 20% was required to satisfy the criterion based on the signal-to-noise ratio. Using this value with the other two criteria predicts the form of the weight-dependent activity schedule as a function of imaging time. Examples of schedules for imaging times of 300 and 600 s are compared with a schedule based on surface area.

Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis

OBJECTIVE

to evaluate the effects of brisk walking on bone mineral density in women who had suffered an upper limb fracture.

DESIGN

randomized placebo-controlled trial. Assessments of bone mineral density were made before and at 1 and 2 years after intervention. Standardized and validated measures of physical capacity, self-rated health status and falls were used.

SETTING

district general hospital outpatient department.

SUBJECTS

165 women drawn from local accident and emergency departments with a history of fracture of an upper limb in the previous 2 years. Women were randomly allocated to intervention (self-paced brisk walking) or placebo (upper limb exercises) groups.

INTERVENTION

both groups were seen at 3-monthly intervals to assess progress, measure physical capacity and maintain enthusiasm. The brisk-walking group were instructed to progressively increase the amount and speed of walking in a manner that suited them. The upper limb exercise placebo group were asked to carry out a series of exercises designed to improve flexibility and fine hand movements, appropriate for a past history of upper limb fracture.

RESULTS

drop-outs from both intervention and placebo groups were substantial (41%), although there were no significant differences in bone mineral density, physical capacity or health status between drop-outs and participants. At 2 years, among those completing the trial, bone mineral density at the femoral neck had fallen in the placebo group to a greater extent than in the brisk-walking group [mean net difference between intervention and placebo groups 0.019 g/cm2, 95% confidence interval (CI) -0.0026 to +0.041 g/cm2, P = 0.056]. Lumbar spine bone mineral density had increased to a similar extent (+0.017 g/cm2) in both groups. The cumulative risk of falls was higher in the brisk-walking group (excess risk of 15 per 100 person-years, 95% CI 1.4-29 per 100 person-years, P < 0.05). There were no significant differences in clinical or spinal x-ray fracture risk or self-rated health status between intervention and placebo groups.

CONCLUSION

the promotion of exercise through brisk-walking advice given by nursing staff may have a small, but clinically important, impact on bone mineral density but is associated with an increased risk of falls. Self-paced brisk walking is difficult to evaluate in randomized controlled trials because of drop-outs, placebo group exercise, limited compliance and lack of standardization of the duration and intensity of walking. Further work is needed to evaluate the best means of safely achieving increased activity levels in different groups, such as older women and those at high risk of fractures.

Assessment of the phenotypic range seen in Doyne honeycomb retinal dystrophy

OBJECTIVE

Using molecular genetics as the basis for diagnosis, to assess the phenotype in the family originally described as having dominantly inherited Doyne honeycomb retinal dystrophy (DHRD) linked to chromosome 2p16.

DESIGN

Clinical examination including fluorescein angiography was undertaken in 107 family members. Nine affected patients underwent electroretinography, perimetry, dark adaptometry, color-contrast sensitivity measurement, and autofluorescent fundus imaging.

PATIENTS

The disease-associated haplotype used to allocate disease status was based on our further refinement of the DHRD locus to between loci D2S2739 and D2S378. The study identified 50 affected patients. In addition, previously published information on a further 8 individuals was used. The study population represented 6 generations of a 9-generation pedigree.

RESULTS

Three types of deposits were seen: large, soft drusen at the macula and abutting the optic nerve head; small, hard deposits that in some patients radiated from the macula; and autofluorescent deposits. Most younger affected individuals exhibited small hard drusen only at the macula and had normal visual function. Information on 2 patients suggested that DHRD can be a cause of childhood-onset blindness. Advanced disease was associated with severe visual loss and posterior pole atrophy without signs of drusen. Advanced age was not invariably associated with severe visual loss.

CONCLUSIONS

Previously identified characteristics of DHRD were confirmed and new features identified. Contrary to previous reports, the constancy and severity of radial (basal laminar) drusen seen clinically are the only features that can be used to differentiate between DHRD and malattia leventinese. The highly variable phenotype suggests that the influence of the DHRD-mutant gene may be modulated by other genetic and/or environmental factors.

Otomycosis: the detection of fungi in ears by immunofluorescence microscopy

The procedure currently used to diagnose infection in otitis externa has several limitations: it is slow to culture organisms on growth media, fungal infections are often missed, and extensive laboratory facilities and mycological expertise are required. A rapid, accurate and sensitive assay would greatly improve patient care by initiating appropriate antifungal treatment at the onset of disease. We report the development of a rapid detection assay for otomycosis using fungal-specific monoclonal antibodies to detect fungi in ear swabs by immunofluorescence microscopy. This assay could form the basis of a detection assay for fungal infections of the head and neck.

Lipid and protein deposition of N-vinyl pyrrolidone-containing group II and group IV frequent replacement contact lenses

PURPOSE

The purpose of this study was to investigate the degree of protein and lipid deposition that occurs on N-vinyl-2-pyrrolidone (NVP) containing group II (non-ionic, high water content) and NVP containing group IV (ionic, high water content) frequent replacement hydrogel contact lens materials.

METHODS

Twenty subjects were fitted with Group II (Vasurfilcon A) and Group IV (Vifilcon A) contact lenses, which were replaced monthly. The lenses were worn as a contralateral pair for 3 consecutive monthly periods. At the end of each monthly period, the lenses were collected for analysis of protein and lipid deposits. Protein deposition (following extraction) was examined by transmission UV and lipoidal deposition was examined using fluorescence spectrophotofluorimetry.

RESULTS

There was a significant difference in the lipid and protein deposition profiles between the two materials. The Group II lens deposited approximately 2x more lipid (38 versus 73 fluorescence units; P < 0.0001) and the Group IV lens deposited approximately 17x more protein (488 micrograms versus 28 micrograms; P < 0.0001). Whilst the mean results across months were not significantly different for either protein or lipid (P = NS), the results revealed significant inter- and intra-subject variation.

CONCLUSIONS

Protein deposition was predominantly controlled by the ionic charge of the lens materials, whereas the lipid deposition was predominantly determined by the NVP content. This study demonstrates that inter-subject variation and material characteristics significantly influence the deposition profile of hydrogel contact lens materials.

Localisation of a gene for dominant cone-rod dystrophy (CORD6) to chromosome 17p

We have performed genetic linkage analysis on a four generation British family with cone-rod dystrophy. Significant linkage to the disease gene was obtained with eight marker loci situated on chromosome 17p12-p13. A maximum two-point lod score of 5.93 with no recombination was obtained with marker locus D17S1844. Critical recombinants identified with flanking marker loci placed the disease gene between D17S796/D17S938 and D17S954, an interval estimated to be 8 cM in size. This new localisation for autosomal dominant cone-rod dystrophy (CORD6) overlaps with regions attributed previously to Leber's congenital amaurosis, central areolar choroidal dystrophy and dominant cone dystrophy. Given their differences in phenotype, the most plausible explanation would be that these different retinal disorders are caused by mutations in different genes mapping close together within the genome.

Effect of storage at -70 degrees C on lipid, lipoprotein and apolipoprotein concentrations

We have investigated the effects on lipid, apolipoprotein and lipoprotein measurements of storing unfractionated serum from normolipidaemic and hyperlipidaemic subjects at -70 degrees C for 10 days, 3 months and 6 months. Total serum concentrations of lipids and apolipoproteins were stable except for triglyceride concentrations. These increased on storage although the change was < 2.0% after 6 months. Storage of serum before sequential flotation ultracentrifugation resulted in decreased free cholesterol and phospholipid concentrations in very low density lipoproteins. In low density lipoproteins, free cholesterol concentrations increased and protein concentrations decreased on storage, while esterified cholesterol and phospholipid concentrations fell after 10 days but did not differ from baseline concentrations after storage for 6 months. Within high density lipoproteins, there were decreases in triglyceride and protein concentrations. Although storage of serum at -70 degrees C for up to 6 months did not result in extensive changes in most lipoprotein fractions, separation of lipoprotein fractions from serum should, ideally, be performed as soon as possible after collection.

Importance of local differences in comparing hospital and community psychiatric services

Most of the studies that are frequently cited as examples of effective comprehensive community care, (i.e. they reduce the demand for hospital beds without any loss in treatment efficacy (Stein & Test, 1980; Hoult & Reynolds, 1984; Muijen et al., 1992) were carried out before the introduction of the Care Programme Approach (CPA) in 1991 (Department of Health, 1990) which at present only applies to England. As the CPA derives from these earlier studies the discrepancies between hospital and community based aftercare might be expected to become less, as now all services in England are expected to include a significant community element. However, there can still be important differences between those services focusing on community care as the main priority and those in which the hospital system is paramount.

The psychiatric services in the area covered by North West London Mental Health Trust (NWL Trust) represented a natural test of these two approaches as they had parallel hospital and community based teams covering the same catchment areas respectively, North Paddington, in Westminster and Brent, in outer London.

At this point it is useful to provide more detailed description of the two geographical areas at the time of the study and the community and hospital based teams that were involved.

Evidence for a major retinitis pigmentosa locus on 19q13.4 (RP11) and association with a unique bimodal expressivity phenotype

Retinitis pigmentosa (RP) is the name given to a heterogeneous group of retinal degenerations mapping to at least 16 loci. The autosomal dominant form (ARP), accounting for approximately 25% of cases, can be caused by mutations in two genes, rhodopsin and peripherin/RDS, and by at least six other loci identified by linkage analysis. The RP11 locus for adRP has previously been mapped to chromosome 19q13.4 in a large English family. This linkage has been independently confirmed in a Japanese family, and we now report three additional unrelated linked U.K. families, suggesting that this is a major locus for RP. Linkage analysis in the U.K. families refines the RP11 interval to 5 cM between markers D19S180 and AFMc001yb1. All linked families exhibit incomplete penetrance; some obligate gene carriers remain asymptomatic throughout their lives, whereas symptomatic individuals experience night blindness and visual field loss in their teens and are generally registered as blind by their 30s. This "bimodal expressivity" contrasts with the variable-expressivity RP mapping to chromosome 7p (RP9) in another family, which has implications for diagnosis and counseling of RP11 families. These results may also imply that a proportion of sporadic RP, previously assumed to be recessive, might result from mutations at this locus.

Biokinetic behavior of technetium-99m-DMSA in children

After intravenous administration of 99mTc-DMSA, biokinetic data were collected from studies on 24 children aged from 5 wk to 14.8 yr (15 normal and 9 with renal pathology).

METHODS

Patients were imaged with a gamma camera up to 30 hr postinjection and the absolute activities in the kidneys, liver, spleen, bladder, knees and whole body were estimated using an attenuation-corrected conjugate counting technique. Renal uptake and elimination rates and urinary excretion of radioactivity were also measured.

RESULTS

In children with normal renal function, maximal kidney uptake was 42.4% +/- 5.4% and was taken up with a half-time of 1.0 +/- 0.2 hr. Renal excretion amounted to 18.0% +/- 4.4% at 24 hr and was lowest in children aged less than 1 yr. In children with abnormal renal function, apart from the expected reduction in renal uptake there was evidence of wider variations in uptake rate and increased urinary excretion. Mean uptakes in liver and spleen were approximately 5% and 2%, respectively, in all patients and uptake in knees, assumed to reside in the metaphyseal growth complexes, was 1.4%.

CONCLUSION

In children with normal renal function, there was little evidence of age-dependent biokinetic factors other than reduced urinary excretion and lower uptake in knees in children aged less than 1 yr. The results therefore suggest that a single biokinetic model may suffice for radiation dosimetry purposes in normal children irrespective of age.

Air hunger induced by acute increase in PCO2 adapts to chronic elevation of PCO2 in ventilated humans

Brief increases in arterial PCO2 (PaCO2) (lasting several minutes) produce a sensation of respiratory discomfort (air hunger). It is not known whether air hunger adapts to chronic changes in PaCO2. This study tested whether the level of end-tidal PCO2 (PETCO2) required to evoke air hunger would increase with chronic elevation of PETCO2 (lasting several days). Four ventilator-dependent subjects participated in a 2-wk study during which they were ventilated with air (placebo) or air rich in CO2 (CO2 exposure). Average resting PETCO2 during control periods was 25 Torr (typical for such patients); PETCO2 was 15 Torr higher during CO2 exposure. Ventilation and arterial PO2 did not differ between conditions. Periodically, we performed tests in which subjects rated the intensity of air hunger induced by brief increases in PETCO2. The increase in PETCO2 required to elicit a given air hunger rating during CO2 exposure also increased by approximately 15 Torr. That is, subjects' sensation of air hunger fully adapted to the chronic increase in PETCO2. Arterial pH did not fully return to control values during CO2 exposure. Accommodation in the chemoreceptors and neural pathways that subserve air hunger sensation may explain the adaptation of air hunger.

Molecular genetics of central retinal dystrophies

A range of chorioretinal dystrophies that principally affect the central retina have recently been associated with either specific genetic mutations or mapped to refined genomic loci. Mutations of two genes, peripherin/RDS (chromosome 6p) and TIMP3 (chromosome 22q) have been shown to be of particular importance to this group of disorders. Other conditions such as Stargardt's disease, Best's disease, pattern dystrophy, cone dystrophy and cone-rod dystrophy have been mapped to different regions of the genome, however the underlying genetic mutations await identification. Molecular genetic diagnostic techniques are now available for a number of central choroidoretinal dystrophies allowing for earlier, accurate diagnosis and laying the groundwork for future studies of potential therapeutic protocols.

Radiation dosimetry of technetium-99m-DMSA in children

Radiation dosimetry was performed on 24 children (aged 5 wk to 14.8 yr) who were undergoing routine diagnostic investigation of renal impairment with 99mTc-DMSA.

METHODS

Organ doses were calculated using MIRDOSE 3 with biokinetic data obtained in previously described studies, and effective doses and effective dose equivalents were estimated. Interpolation by inverse weight between pediatric anthropomorphic phantoms was compared with age-matching to discrete phantoms. Administered activities were scaled by body surface area from the adult activity of 100 MBq and the resulting radiation doses in normal children were compared with those that would have resulted from a schedule based on body weight.

RESULTS

The effective doses estimated by interpolation differed by up to 46% from those based on discrete phantoms and showed less variation. In children with normal bilateral renal function, the mean effective dose per administered activity was 0.91 +/- 0.08 mSv or 0.98 +/- 0.29 mSv by the two methods, respectively. Renal pathology reduced the effective dose, on average, by 15% of the value for normal patients.

CONCLUSION

Over the pediatric age range, the uniformity of effective dose values was improved by scaling the administered activity according to body surface area rather than to body weight.

Doyne revisited

Inherited retinal dystrophies are important causes of blindness in the Western world. Molecular genetic techniques, and the use of large pedigrees exhibiting such conditions, have been instrumental in finding causative disease genes. The genealogy of families with a rare condition known as Doyne's honeycomb retinal degeneration was first described in 1899. Investigating this phenotype is extremely important because of the similarities it shares with age-related macular degeneration, and it may lead us to a gene that is involved in this complex genetic trait. In this paper we review the original genealogy of the families described by Doyne, and explain the methods used to identify the living descendants of these families.

The gene responsible for autosomal dominant Doyne's honeycomb retinal dystrophy (DHRD) maps to chromosome 2p16

Degeneration in the macula region of the retina is a feature of a heterogeneous group of inherited, progressive disorders, causing blinding visual impairment. Autosomal dominant Doyne's honeycomb retinal dystrophy (DHRD) is characterised by the presence of drusen deposits at the level of Bruch's membrane in the macula and around the edge of the optic nerve head. We have studied 63 members of a large, nine-generation British pedigree by linkage analysis. Two-point analysis showed significant linkage to nine markers on the short arm of chromosome 2, a region overlapping that recently reported to be linked to Malattia leventinese. A maximum lod score (Zmax) of 7.29 (theta = 0.0) was obtained at marker locus D2S2251. Haplotype analysis of recombination events localised the disease to a 5 cM region between marker loci D2S2316 and D2S378. Striking clinical similarities between DHRD and the more common condition age-related macular degeneration (ARMD) suggest that the disease gene at this locus could be considered as the most likely candidate in future studies on ARMD.

Clinical features of progressive bifocal chorioretinal atrophy: a retinal dystrophy linked to chromosome 6q

PURPOSE

The gene for progressive bifocal chorioretinal atrophy (PBCRA) has been linked to chromosome 6q, near the genomic assignment for North Carolina macular dystrophy. A study was undertaken to define the clinical features of a large PBCRA pedigree and to determine whether PBCRA and North Carolina macular dystrophy are phenotypically distinct entities.

METHODS

Fifteen affected individuals from 1 large family were examined clinically, which included angiography and electrophysiologic studies.

RESULTS

The PBCRA is an autosomal dominant chorioretinal dystrophy of early onset characterized by large atrophic macular and nasal retinal lesions, nystagmus, myopia, poor vision, and slow progression. A large atrophic macular lesion and nasal subretinal deposits are evident soon after birth. An atrophic area nasal to the optic nerve head appears in the second decade, which enlarges progressively. Electro-oculographic and electroretinographic studies indicated marked, diffuse abnormalities of rod and cone function. Fluorescein and indocyanine green angiography showed a large circumscribed area of macular choroidal atrophy with staining of deposits in the peripheral retina. In addition to previously documented features, nasal retinal abnormalities from a few weeks of age, marked photopsia in a number of patients, and retinal detachments in three eyes are reported as new features of the disease.

CONCLUSIONS

An extended description of PBCRA is presented highlighting that the phenotype is distinct from North Carolina macular dystrophy, although some phenotypic similarities exist between the two conditions. These disorders may be the result of different mutations on the same gene or nearby genes.

Molecular analysis of an extra inv dup(15)(q13) chromosome in two patients with Angelman syndrome

Angelman syndrome (AS) is caused by the loss of function of yet unidentified gene(s) which map within 15q 11-13 and show monoallelic expression from the maternal allele. Lack of the maternal allele(s), due to either a deletion on the maternal chromosome 15 (about 70% of AS patients) or a paternal uniparental disomy (UPD)15 (<5%), are the most common molecular defects in AS. Prader-Willi syndrome (PWS) also maps to proximal 15q, but is caused by the loss of function of paternally expressed gen(s) [1]. Here we describe clinical, cytogenetic and molecular data for two non-related patients with AS who carry a nonmosaic extra cromosome inv dup(15).

Bronchogenic carcinoma and coexistent bronchioloalveolar cell adenomas. Assessment of radiologic detection and follow-up in 28 patients

PURPOSE

Bronchioloalveolar cell adenomas (BAAs) have been described in up to 10% of patients with bronchogenic carcinoma. Their prognostic significance is unknown. The purpose of this study was to determine the prognostic implications of finding BAAs coexisting in specimens resected for primary bronchogenic carcinoma and to determine how frequently BAAs can be detected radiologically.

METHODS

Follow-up information for a mean of 30 months was obtained on 28 patients with a single primary bronchogenic carcinoma and one or more coexistent BAAs. Preoperative chest radiographs (n=27) and CT scans (n=24) were retrospectively reviewed to assess the number of patients in whom BAAs could be detected radiologically.

RESULTS

There was no significant difference between percentage survival of patients with a primary bronchogenic carcinoma and coexistent BAAs when compared with the percentage predicted survival of these patients based on their primary bronchogenic carcinoma alone. BAAs could be detected retrospectively in 1 of 27 (4%) preoperative radiographs and 11 of 24 (46%) CT scans.

CONCLUSIONS

On standard preoperative imaging for bronchogenic carcinoma, BAAs were retrospectively detected in more than one third of patients in whom they were detected pathologically. However, the presence of coexistent BAAs with bronchogenic carcinoma does not affect short- and medium-term prognosis.

Surgical clips in planning the electron boost in breast cancer: a qualitative and quantitative evaluation

PURPOSE

To evaluate, qualitatively and quantitatively, the role of surgical clips in planning the tumor bed electron boost in patients undergoing breast conserving surgery and radiotherapy.

METHODS AND MATERIALS

In 50 patients, the excision cavity boundaries were marked by clips at surgery. The electron boost field was first planned using clinical information, aiming to achieve a margin of 2 cm, and its accuracy evaluated by screening the surgical clips and, if necessary, adjusting the field to encompass all clips with 2 cm margins. Orthogonal radiographs were take with solder wire delineating the clinical and screened fields and the scar. Hypothetical clinical and radiological fields, with 1 and 3 cm margins, were reconstructed on the radiographs.

RESULTS

The clinical field was inadequate in 34 patients (68%). The precision of each clinical setup was quantified by two indices. The Normal Tissue Index defined the percentage of the clinical field comprised of tissue, beyond the tumor bed, not at high risk of local recurrence, and gave an estimate of potential spring of normal tissue: median 14.6% (range 0-83.0), 17 out of 50 > 25%; median 13% (range 0-70.7), 12 out of 50 > 25%; median 9.7% (range 0-59.8), 10 out of 50 > 25%, for 1, 2, and 3 cm margins, respectively. The Geographical Miss Index defined the percentage of the radiologically defined field, at high risk of local recurrence, not predicted by the clinical field, and gave an estimate of the extent of geographical miss: median 32.9% (range 0-83.5), 28 out of 50 > 25%; median 26.1% (range 0-69.8%), 26 out of 50 > 25%; median 18.6% (range 0-60.3), 20 out of 50 > 25%, for 1, 2, and 3 cm margins, respectively. The median distance from the scar midpoint to the furthest clip was 3.8 (range 1.2-8.1) cm. The median maximal clip depth was 3.1 (range 1.4-5.2) cm.

CONCLUSION

(a) Electron boost field planning by clinical landmarks alone was inaccurate in 68% of cases. (b) Quantitative measures, based on margins of 1, 2, and 3 cm, revealed that in 20-34% of patients more than one-quarter of the clinical field covered tissue at low risk of local recurrence, and in 40-56% of patients less than three-quarters of the final radiological field was predicted clinically. (c) The relative positions of the scar and clips may be widely disparate. (d) Clip depth measurements reveal a significant risk of underdosing at depth.